8451.1 - Physical Restraint and Seclusion Guidelines



Student: ___________________________________   NSSRS Number: _______________ Date: ____________


Age: _____  Grade: ____  Racial ethnicity status:_____________ IEP: ? Yes  ? No  Case manager:___________


If IEP, verified disability: _________________________     Function based behavior plan in effect:  ? Yes  ?  No


Duration Time of event (beginning/ending): ______________ Setting and location: ________________________


Person preparing this report: ___________________ List of personnel who participated in the implementation,

monitoring, and supervision of restraint or seclusion: ________________________________________________


Name of Parent/Guardian notified: ______________________________________   Time: __________________


Method of contact: ____________________  Person making contact: ___________________________________


A description of events leading up to the incident (may use back for restraint incident):



A log of student behavior that resulted in implementation of physical restraint or seclusion including a description

 of injury which resulted in restraint or seclusion:



A description of any injuries to students, staff or others, or property damage:



Has a safety plan been developed for this individual? Include a description of planned interventions (If yes, please

attach a copy of  the plan with this form.)  If  NO, when will the safety plan be developed? ___________________


Discussion with student and/or debriefing/follow up plans with staff:



If applicable, is an IEP meeting needed? ? Yes  ?  No  If yes, date scheduled:_____________________________



Examples and Clarification


Restraints are never permitted for non-compliance. There must be imminent danger to the student or other persons to justify a restraint. It must be applied by trained staff, and only when lesser interventions, such as removal of an audience, will not suffice to reduce safety risks. There must be one lead staff member authorizing the restraint. All restraints require a restraint and or incident report even if the student has received restraints in the past and methods of safely restraining are specified in a behavior plan. All students who have received two or more restraints in a setting should have a function-based behavior plan developed to address the triggers of problem behavior in the specific environment in which it occurred. This form must be completed in ink with no white out. Staff may wish to record incidents in which a restraint may have resulted, but lesser interventions were used that reduced safety risk.



Signature of person completing this form ___________________________________________________    Date: ___________


Copies to: Parent/Guardian, student’s file, and Case Manger

     Describe Student Behavior/ Description of Incident

Check Staff Response Used/ Emergency Intervention

Escalation Stage

ANXIETY: observed/not observed

Who addressed if observed:

____ proximity

____ counseling

____ restructure routine/environment

____ accommodate materials/expectations

____ referral to:


Description of events:





DEFENSIVE: observed/not observed

(question, refuse, vent, intimidate)

Who addressed if observed:

____ redirect, restate direction

____ counseling

____ restructure routine/environment

____ accommodate materials/expectations

____ referral to:

Description of events:







DANGEROUS BEHAVIOR: If physical restraint, must include type, rationale, length of time, etc. (use back of this form as needed:

Intervention Leader: ______________________________

____ clear area                                               ____ call administrator

____ one person side body hug restraint

____ block                                                       ____ other

____ one arm standing restraint                   ____ visual

____two person one arm standing restraint         supervision


Description of events:





De- Escalation


____ review events                                ____ review schedule

____ make plan:



Description of events:






____ sent to nurse                                ____ 911 procedures

____ released to parent                        ____ CPR

____ first aid

____ transported to:

Description of Property Damage (include cost/consequence)